Abstract
Gender is an intersectional determinant of health that remains insufficiently integrated in programmes and policies. Sustained processes of dialogue and collaboration, including participatory approaches such as co-design, are needed to effect gender integration. However, the contexts and power dynamics through which co-design may support gender integration are not well understood. This qualitative case study examined a co-design partnership that undertook gender integration within an established adolescent sexual and reproductive health programme in South Africa from 2022-2025, drawing on (n = 37) project documents, (n = 36) post-meeting reflections, (n = 2) annual project group reflections, and (n = 12) key informant interviews. Analysis was deductive-inductive and informed by theories of context, organisational logics, gender, and power. Three interlinked contextual levels influenced the partnership. Macro-level funding arrangements and accountability structures created hierarchical pressures that constrained participatory and gender-responsive work. Meso-level organisational logics differed across partners, creating misalignment with the reflective co-design approach and between partner organisations. At the micro-level, boundary-spanning individuals enabled trust-building and adaptation. Interactions across levels revealed how institutionalised power shaped feasible forms of participation and gender integration. Co-design partnerships can strengthen gender integration in programmes but require macro-level enabling systems, institutional support, and navigation of meso-level organisational logics alongside sustained micro-level action.